4Concerns of women with rheumatic disease Will I be able to get pregnant? Stay pregnant? How will my disease affect the pregnancy? How will the pregnancy affect my disease during pregnancy and post partum? In the long run? Which drugs are safe during pregnancy
5Concerns of women with rheumatic disease Can a disease flare be treated safely during pregnancy?Can I breastfeed?What is the risk of passing my disease to my child?
6Lessons learned from the patients Many doctors know little about the interaction of pregnancy and rheumatic diseaseDoctors often forget to address family planningNo structured plan for interdisciplinary monitoring of disease during pregnancyMany unanswered questions about drugs during pregnancy and lactation
11Risk for the SLE mother during pregnancy FlarePregnancy complications (2-4 fold higher in SLE pregnancies)HypertensionPreeclampsia/HELLPOther complicationsPremature delivery and Cesarean section
12Lupus activity in pregnancy Clowse M, 2007; Doria A 2002 Tow to three -fold increase in SLE activity during pregnancy.Some activity in 35–70% of SLE pregnanciesThe risk for a moderate to severe flare is 15–30%Risk for flare x 7.25 if SLE active before conceptionMost common activity:SkinJointsHematological
13SLE pregnancies carry significantly higher risks for adverse outcomes
14Lupus nephritis and pregnancy Associated with increase in adverse maternal and fetal outcomes independent of histology of lupus nephritisPregnancy-associated decline in renal function associated with severe renal impairment (Cr>250μmol/l) at conception.Conception with preserved renal function (Cr<125μmol/l) is not associated with irreversible deterioration.
15Maternal complications in SLE pregnancy Bramham et al. J Rheumatol 2011, 107pregnancies
16Differentiation of worsening SLE renal disease from preeclampsia: often mixed picture Clinical measurePreeclampsiaSLE nephritishypertension++/-24 hr. urine proteinDose not differentiateOnset of proteinuriaAbruptGradual /abruptUrine red cell cast/active sedimentRareCommonLiver function testMay be elevated in HELPnormalAbdominal painthrombocytopeniaMay be presentComplementNormal or highlowAnti-Ds DNANegative or stablePositive /increasingUric acidHighNormalUrine calciumOther SLE symptomsNot present
18Presence of auto-antibodies and associated risk for mother and child
19Neonatal lupus syndromes Caused by transplacental passage of SS-A (anti-Ro) and SS-B (anti-La antibodies)Sjögren syndrome, SLE, MCTD, RATransient NLS (skin, cytopenia, liver enzymesCongenital heart block
20Risk of congenital heart block in SSA/SSB positive mothers In primigravidae 1-2%Higher when 1st degree AV-block is considered Sonnesson et al. Arthr Rheum 2004Higher in Sjögren‘s syndrome than SLE3-5 times higher risk if already one child with CHB (15-19% CHB children)Recommendation: weekly Doppler fetal echocardiography from gestational week 16 to 26, then bi-weekly control to week 32 (Jill Buyon)
21Risk assessment necessary for pre-pregnancy counseling AgePrevious pregnancy complications?Irreversible organ damage present?Recent or current disease activity?Antiphospholipid antibodies / APS?Positivity of anti-Ro / anti-La?Current treatment with feto toxic drugs?Treatment with high doses of glucocorticoidsOther chronic medical conditions?Smoking?
22The right time and right condition for pregnancy In remission or stable low disease activity for at least 6 monthsPatient on stable medication with drugs compatible with pregnancyFrequency of medical controls plannedContact established between doctors involved in follow-up during pregnancy
23Reasons to postpone or contradict pregnancy Patients with active disease during the last 6 monthsActive in any organ systemTherapy with teratogenic drugsPatients with severe organ manifestationsSevere renal, pulmonary, cardiac, CNS impairment or severe organ damage
25Pregnancy outcome in 69 SLE subjects 69 pregnancies from 36 SLE Patients were analyzedFrom January 2006 till July 2012Lupus activity index was used (SLEDI)The aim was to determine the frequency of abnormal pregnancy out comes in a cohort of SLE patient to identify the clinical ,laboratory factors predicting fetal outcomes
29ConclusionSLE in pregnancies in Qatar population were associated with higher risk adverse pregnancy outcomes.Disease activity during pregnancy, proteinuria, lupus nephritis and eclampsia/preeclampsia were all negatively associated with pregnancy outcome such as IUGR, still births and preterm delivery.Anti-Ro/La antibodies and low level of C3 were also associated with adverse pregnancy outcomes.
30Summary and take home message Educate patients early and oftenKnow and recommend appropriate contraceptionR0le out serious underlying disease related damageTiming is critical : best maternal and fetal out comes is with quiescent disease at conceptionReview medication before pregnancy and change to pregnancy-compatible meds.Counsel patient/partner ahead of timeClose monitoring with rheumatologist ,OB,and other specialty if needed .